565801527-6-7-2023-29-AS-DPEA-CT6VSY-20230626164219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801527
Report Date: 06/07/2023
Date Signed: 06/07/2023 01:04:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210827202238

FACILITY NAME:	MOM'S PLACE 1		FACILITY NUMBER:	565801527
ADMINISTRATOR:	DMITRY BOLOTSKY		FACILITY TYPE:	740
ADDRESS:	4 MANSFIELD LANE		TELEPHONE:	(805) 383-9896
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 5	DATE:	06/07/2023
		UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Laila Kulungu		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility staff failed to seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today, with the purpose of delivering findings for the above listed allegation. The LPA arrived at 12:18PM and met with Facility Designee Laila Kulungu. The LPA informed Facility Designee of the reason for today's inspection. Entrance interview conducted.

During today’s visit, LPA obtained copies of documents related to Resident #1 (R1.) During an initial complaint inspection conducted on 08/31/2021, LPA Dulek and Administrator Lina Bolotsky conducted a facility tour at 1:05PM. LPA conducted staff interview at 1:25PM. LPA gathered copies of pertinent documents and phone numbers for additional contacts. Throughout the course of the investigation, LPA conducted telephone interview with other relevant parties and reviewed relevant documents. The following was then determined:

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210827202238

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOM'S PLACE 1	FACILITY NUMBER: 565801527
	VISIT DATE: 06/07/2023

NARRATIVE

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The complaint alleges that facility staff failed to seek timely medical attention for R1. Incident report submitted to the Woodland Hills Regional Office on 08/29/2021 indicates that R1 vomited around 05:00PM on 05/26/2021. It also noted that R1 appeared weak. Interviews revealed it was not unusual for R1 to be dizzy, have motion sickness or to vomit. R1’s responsible person was present at the facility that evening when R1 vomited. Administrator contacted R1’s primary care physician, who instructed staff to continue to observe R1 and to call 9-1-1 if R1’s condition worsened. Interview revealed that R1 drank a protein drink and electrolyte drink and then went to bed as usual. R1 did not not vomit any additional times. When R1 awoke the next day, R1 appeared lethargic and weak. Administrator contacted R1’s responsible person, facility staff called 9-1-1 for further medical attention and R1 was transported to the hospital around 09:00AM on 08/27/2021. Interview revealed that although R1 vomited and appeared weak the night before that it was at R1’s physician’s direction that staff did not call 9-1-1 immediately. Although they did not call 9-1-1 immediately following R1’s vomiting, facility staff and Administrator did seek out medical attention that evening, as evidenced by contacting the resident’s primary care physician for further instructions. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff failed to seek medical attention in a timely manner” is deemed UNSUBSTANTIATED at this time.

No citations were issued. Exit interview conducted. A copy of today’s report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC9099 (FAS) - (06/04)

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